breast is normally soft and looks natural
breast is a little firm but looks normal
breast is firm and looks abnormal
breast is hard, painful, and looks abnormal
Capsular contracture may require reoperation, usually for Grades III and IV, and it may occur again.
Reported rates of capsular contractures vary widely, ranging from 1.3 to 30 percent of patients who receive implants.The longer the implants were in place, the greater the cumulative risk of developing contracture, which would suggest a direct correlation between when the implant is placed and the time to developing contractures.Approximately 92 percent of contractures occur within the first 12 months following surgery.A number of parameters seem to influence the occurrence of contractures, including the indications for surgery (breast reconstructions versus cosmetic augmentations), type of prosthesis used (smooth versus textured and saline versus silicone), and positioning of the implant (subglandular versus submuscular).
In the first meta-analysis, Barnsley et al. proved the protective effect of textured implants over smooth surfaces (relative risk, 0.19; 95 percent confidence interval, 0.07 to 0.52), with smooth implants showing a five-times greater risk of contracture formation.In the second meta-analysis, 235 patients were analyzed, and textured implants were shown to produce fewer capsular contractures when compared with smooth implants at 1 year (relative risk, 4.2; 95 percent confidence interval, 1.6 to 11.0), 3 years (relative risk, 7.3; 95 percent confidence interval, 2.4 to 21.7), and 7 years of follow-up (relative risk, 3.0; 95 percent confidence interval, 0.9 to 10.4).Only one study showed no significant differences between smooth versus textured implants for the occurrence of capsular contractures. However, this trial had a Jadad score of 2, indicating a poor methodologic quality with a high degree of variance in the results.
Seckel and Costas retrospectively studied 76 patients (146 breasts) who had undergone partial or total submuscular breast cosmetic augmentation. No difference was observed between the total and the partial musculofascial coverage for the occurrence of capsular contractures [zero of 35 (0 percent) versus one of 41 (0.02 percent); Fisher's exact test, p = not significant].Hendricks reviewed 650 patients who had received textured silicone gel implants beneath the pectoralis major muscle, the external oblique muscle, the rectus sheath, and the serratus anterior muscle fascia. In this study, no cases of Baker grade 3 or 4 capsular contractures were reported.
It is a nice review of the literature which points out the short comings of our knowledge.Ventura and Marcello retrospectively analyzed 100 patients who had received primary breast enlargement with textured implants positioned in the subfascial compartment and found that only two patients (2 percent) experienced Baker grade 2 capsular contractures.Finally, in a retrospective multicenter study of more than 500 patients, Gutowski et al. found that the use of subglandular positioning of the prosthesis increased the risk of capsular contractures by almost eight times.
Although it is apparent from the articles studied in this review that a great deal of progress has been made over the past few decades toward elucidating the etiopathogenesis of capsular contractures, the exact nature and contribution of molecular, immunologic, and microbiological factors remain unclear.Only a few studies have included large enough sample sizes, were conducted in a prospective manner, were adequately randomized, and achieved adequate follow-up periods to obtain a true measure of the rates of capsular contracture occurrence.Therefore, there is a scant and often inconclusive body of evidence relating to this complication. For example, the contribution of chemotherapy to the occurrence of capsular contractures warrants more thorough investigation.Likewise, the possibility of preventing this complication by use of experimental drugs needs to be looked at more closely.Revision surgery remains the only effective treatment option available to us at this time but is limited by its high associated risk of recurrences and complications (hematoma or pneumothorax) when the implant is originally placed in the submuscular position. It is hoped that future studies will focus on attempting to resolve some of the issues highlighted in this review.